Autofluorescence findings and role of anti-vascular endothelial growth factor in inflammatory choroidal neovascular membrane Autofluorescence in posterior uveitis

central area, consistent with atrophy of the RPE.[5] 7. Birdshot chorioretinopathy: In this disease the early lesions do not necessarily cause autofluorescent abnormalities, but hypo autofluorescence is usually associated with the depigmented lesions suggesting RPE atrophy. Linear hypo autofluorescent streaks along the retinal vessels and placoid hypo autofluorescence in the macula can also be seen. 8. Vogt-Koyanagi-Harada disease: Serous detached areas show hypo-autofluorescence due to the blockage. After resolution of the serous detachment, numerous hypoautofluorescence granular dots correspond to the window defects on FFA and areas of RPE damage or atrophy, clinically.


Autofluorescence findings and role of anti-vascular endothelial growth factor in inflammatory choroidal neovascular membrane
Dear Editor, I read the article by Dhingra et al., [1] which describes the pathogenesis and treatment of the inflammatory choroidal neovascular membrane (CNVM).I would like to add a few comments about the autofluorescence (AF) findings and use of the anti-vascular endothelial growth factor (VEGF) in inflammatory CNVM.

Autofluorescence in Inflammatory CNVM
Many reports showed the utility of AF as a marker for early disease and in predicting the outcome of treatment in CNVM

Autofluorescence in posterior uveitis
Dear Editor, I read the article by Sudharshan et al., [1] which describes the current approach in posterior uveitis.I would like to congratulate the authors for an excellent comprehensive review and to add a few comments about autofluorescence (AF) in various posterior uveitic conditions.
The amount of AF is determined by the amount of fluorophores, which varies during the acute and resolution phases of inflammation.Hypertrophy and reactive hyperplasia of retinal pigment epithelium (RPE) is associated with increase in AF, due to accumulation of flurophores.A transmission defect during fundus fluorescein angiography (FFA), because of RPE atrophy, appears to be hypoautofluorescencent.
Following are the important AF findings reported in various chorioretinal inflammatory conditions:

Multiple evanescent white dot syndrome (MEWDS):
In the acute phase of MEWDS, AF photography shows less numerous, but increased AF areas, corresponding to the focal hypocyanescent spots seen on indocyanine green angiography (ICG), probably due to the excitation of the photoreceptor-retinal pigment epithelium complex.Following resolution of the lesions, AF and ICG return to a normal pattern. [2]

Acute syphilitic posterior placoid chorioretinitis: A yellowwhite placoid lesion in the macular area in this disease
shows increased AF, which may be due to the accumulation of lipofuscin in the RPE or to imperfect phagocytosis and processing of the photoreceptor outer segments in the acute phases of the disease.With treatment, the yellow color, opacification of the retina, increases the autofluorescence resolve. [3]

Multifocal choroiditis and panuveitis (MCP): In MCP, AF
shows numerous hypo-autofluorescent spots corresponding to the clinically visible chorioretinal scars, but more in number. [4]This indicates more extensive RPE damage compared to the clinically visible damage.

Serpiginous choroiditis (SC):
In SC, hyper-autofluorescence is seen two to five days after the appearance of the lesions, which progressively decreases during the scarring phase of the disease.

Acute zonal occult outer retinopathy (AZOOR): Zonal
damage in AZOOR is characterized by an intensely autofluorescent outer border of the affected zone, consistent with the presence of lipofuscin and a hypo-autofluorescent due to age-related macular degeneration.There are very few reports on AF findings in inflammatory CNVM.
Inflammatory CNVM, which is usually of the classic type (type 2), is seen on AF photography as a precise hyper-autofluorescent area due to the hyperplastic retinal pigment epithelium (RPE).Following treatment, CNVM may contract and leave a zone of absent RPE causing a hypoautofluorescence.
Secondary choroidal neovascularization in multifocal choroiditis and panuveitis (MCP) is readily visible as a hyper-autofluorescencent area originating from a hypoautofluorescent spot (scar).With increasing follow-up time, the hyper-autofluorescence associated with CNV decreases.AF imaging provides a method to image the appearance of new or enlarging spots that appear, which is more sensitive than using ophthalmoscopically visible signs.
More studies are required to understand the role of AF in inflammatory diseases.AF imaging could be an important noninvasive tool to reduce the need for angiography and to help in early diagnosis, as also in the follow-up of inflammatory CNVM patients.

Use of Anti VEGF in Inflammatory CNVM
There are potential disadvantages of treating inflammatory CNV with photodynamic therapy (PDT).PDT can cause localized inflammation and increase VEGF production.Local release of VEGF, after PDT, may be associated with a higher incidence of recurrent choroidal neovascularization (CNV). [2]an et al studied 10 patients with CNV, who were refractory to previous immunosuppression and PDT or intravitreal triamcinolone (IVTA).They reported that intravitreal bevacizumab improved the best corrected visual acuity (BCVA) and reduced the central macular thickness in the eyes with 2.5 injections (mean), and this was seen at 7.5 months of follow up.In this study they included a patient who recurred three months after pegaptanib injection and responded well. [3]Fine et al reported successful treatment of inflammatory CNVM with ranibizumab in a patient with multifocal choroiditis and pan uveitis (MCP), who did not responded to bevacizumab or the PDT and IVTA therapy. [4]e recent and largest case series by Monsour et al reported significant improvement of 2.2 lines in BCVA at 24 months, with a significant decrease in foveal thickness (265 microns), with only 1.3 injections (mean).This study confers the long-term benefits of intravitreal bevacizumab. [5]rious side effects and chances of recurrence make PDT an obsolete treatment option.Recent promising results favor intravitreal bevacizumab as a primary / mono therapy in inflammatory CNVM.

Management of bilateral idiopathic healed sclerokeratouveitis with ciliary and intercalary staphyloma with complicated cataract and secondary glaucoma
Dear Editor, We read the article by Parihar et al. [1] and agree with their conclusions and would like to share the course of a uveitic glaucoma with intercalary staphyloma which was managed well with phacoaspiration, posterior chamber intraocular lens (PCIOL), and Ahmed glaucoma valve (AGV) implantation.Uveitic glaucoma is challenging due to the early onset and the numerous mechanisms of pathogenesis including steroidinduced intraocular pressure (IOP) elevation. [2]Medical and surgical interventions though initially successful eventually fail due to fibrosis. [3,4]32-year-old lady with recurrent episodes of pain and redness in both eyes (BE) for 3 years was referred to our center with uncontrolled high IOP in left eye.She was on topical timolol maleate 0.5%, brimonidine tartrate 0.15%, and dorzolamide 2% twice daily in BE since 6 months and complained of progressive diminution of vision, dark coloration of the sclera, and white opacities on the cornea for 1 year.There was not any history of ocular injury, fever, joint pain, skin lesions, or any other systemic illness.
On examination, vision in the right and left eye was 1/60 and 20/200, respectively.Both eyes had vascularized maculoleucomatous corneal opacities, normal anterior chamber depth, annular posterior synechiae, patent peripheral iridectomies, and cataract.She also had bilateral ciliary and intercalary staphyloma more in the right than the left eye.Tonopen reading in the right and left eye was 20 mmHg and 40 mmHg, respectively.Fundus and gonioscopy examination was not possible due to media opacities [Fig.1].